APS Grant enables development of brief intervention for humanitarian crises

The APS Grant for Intercultural and/or International Projects of up to $10,000 supports innovative projects that have an intercultural and/or international focus, particularly in countries where psychology is an emerging discipline. Dr Katie Dawson MAPS, Postdoctoral Fellow from the University of NSW, was awarded an APS Grant in 2012-13 for a project based at the World Health Organization in Geneva addressing mental health needs in under-resourced countries affected by trauma and loss. The APS Grant enabled the development of a low-intensity intervention appropriate for different cultural and humanitarian settings. Katie shared her experiences and insights about the APS Grant project with InPsych.

What did the project involve?

Mental health disorders are significant contributors to the global burden of disease, and while mental health does not discriminate across socio-economic status, access to effective psychological interventions currently does. The majority of populations in low and middle-income countries (LAMICs) do not have access to effective psychological treatments, such as CBT. While it is clear these therapies are available, they are often resource intensive (e.g., cost of mental health professionals), thus presenting a perennial impediment to their utilisation in lower income settings. Humanitarian crises are most likely to occur in lower income settings, and there is therefore a pressing need for these affected communities to have more ready access to psychological support.

My collaboration with Dr Mark van Ommeren at the World Health Organization (WHO) has focused on the development of a transdiagnostic, low-intensity psychological intervention that could be disseminated and evaluated across different cultural and humanitarian settings. The intervention, named Problem Management Plus, aims to alleviate some of the general symptoms of common mental disorders via the provision of therapeutic strategies with a firm evidence base, namely CBT and problem-solving techniques. The brief intervention aims to provide psychological support for people in communities that are exposed to adversity from humanitarian crises. Essentially, Problem Management Plus is an extension or ‘step up’ from Psychological First Aid typically delivered in the immediate aftermath of a traumatic event. More akin to interventions offered in the weeks to months following a major traumatic event, such as Skills for Psychological Recovery, Problem Management Plus has adopted a skills-training model to imbue mastery in individuals to respond adaptively to their own distress and practical problems.

In Problem Management Plus, individuals are seen for five weekly sessions of 90 minutes duration. In this time, they are taught the following empirically-supported strategies: problem-solving; behavioural activation; in vivo exposure; accessing and strengthening social supports; and basic stress management. Three months following the completion of the program, participants are invited back for a follow-up assessment and booster session to support the preservation of their therapeutic gains.

How did you come to be involved in the project with the WHO in Geneva?

My involvement in this collaboration with the WHO resulted from my previous work on cultural adaptations of trauma-focused psychotherapy with trauma specialist Professor Richard Bryant FAPS. These trauma projects included adapting CBT for refugees and Australian Indigenous communities, and a community intervention in Aceh, Indonesia. Based on this work, in 2013

I was invited to guide the development and writing of the low-intensity psychological intervention for communities residing in humanitarian settings in low- and middle-income countries.

How did the APS Grant assist your work in Geneva?

The APS Grant enabled me to work in Geneva for two months while writing the treatment manual for Problem Management Plus. In this time I met with key stakeholders in the WHO and UNHCR and established professional relationships with experts in the field of global mental health. The financial support from the APS Grant was integral to the genesis of this project, which has now received further independent funding to enable it to be evaluated in two trauma-exposed communities, one in Pakistan and the other in Kenya. I have remained involved in these research projects, training lay counsellors delivering Problem Management Plus.

What are some immediate or potential applications of your work within particular cross-cultural and low income settings around the world?

Up-skilling lay workers to deliver psychological interventions in their communities, often referred to as “task-shifting”, is one of the most enlivening and immediate applications of my involvement in this project. Since working with WHO we have now received several research grants to evaluate the effectiveness of Problem Management Plus in Peshawar, Pakistan and Nairobi, Kenya. I have conducted training in both countries this year.

In Pakistan, we have adopted a train-the-trainer model due to the security risks restricting foreigners’ travel to Peshawar. Training was conducted in Islamabad in January this year with a small group of Pakistanis with some mental health experience (e.g., postgraduate trained counsellors and psychologists). These trainees have gone on to complete training with less experienced lay counsellors who are currently delivering the treatment in a primary health care setting. Clients are adults affected mostly by the recent surge in sectarian violence in the area.

In Kenya, we are conducting a randomised clinical trial to evaluate the effectiveness of the treatment compared with current treatments for women affected mostly by community and domestic violence and chronic adversity, such as poverty. I have recently returned from training volunteer community health workers with no mental health experience to deliver the treatment.

In what ways has the project’s location within the WHO enhanced its potential impact and advanced the discipline of psychology?

Members of the APS have a sound appreciation of the role rigorous research plays in advancing our discipline. However, currently most studies (almost 90%) that provide the strong evidence base for the treatments we deliver are conducted in high-income settings. The gap in the literature for low-income countries is vast and I believe extending the APS relationship into the international and public health community will go a long way to advance the discipline of psychology in LAMICs. There is no doubt such collaborations will also advance the international profile of the APS in a positive way.

Currently we are testing the effectiveness of Problem Management Plus as a low-intensity psychological intervention delivered by lay counsellors. Following these studies in the coming years, it is expected Problem Management Plus will be freely available through WHO to global organisations and mental health departments for implementation in various humanitarian settings.

What kinds of personal qualities and professional skills were most valuable to you in this project?

It is interesting to reflect on previous APS Grant recipients’ responses to this question. The three words that immediately came to mind were the same others have referred to in the past – flexibility, openness and curiosity. By no means do I consider this a mere coincidence. These are probably the three most valuable and essential qualities for this kind of work.

For me, while my experiences in academic and research settings have been invaluable to my involvement in this project, I also had to adjust very quickly to work effectively in a public health setting. Initially it felt like learning a new language! For instance, writing a generic low-intensity treatment manual in simple and plain language was more challenging than I expected.

My subsequent involvement in the training aspects of this project has accentuated the value of creativity and respecting the inestimable expertise of lay counsellors in developing countries. Working with people of diverse cultural backgrounds and levels of education has taught me so much about my own skill set. I learned the importance of putting aside my own expertise to truly value the inherent clinical knowledge and skill of the trainees. This also requires flexibility with one’s own training approaches, schedules and agendas, as well as concepts of time!

In addition, having an openness and curiosity to the cultural disparities in the expression of distress and coping responses is vital to establishing face validity of foreign therapeutic concepts and techniques. Professionally, acquiring the skill of adapting Western-based therapeutic strategies to cultural practices without diluting the key concept is imperative.

And when working with Kenyan women, be prepared to dance!

Is there a take-home message for us as psychologists here in Australia, and as global citizens?

Throughout my collaboration with the WHO on this project, I have really been challenged to consider how we might disseminate evidence-based psychological interventions in cost-effective ways. I would encourage those who work in the mental health field, regardless of your title, qualifications and degree of training, to be open to the idea that our treatment modalities are able to be disseminated. They can be adapted in a way that facilitates delivery by someone with little to no prior mental health training or experience provided you have the passion and dedication for “task-shifting”.

The psychology training we receive in Australia puts us in a position where we can really be leaders in this area of global mental health. There are many opportunities to build partnerships with local organisations and research facilities, and extend the study of cross-cultural mental health and dissemination of valuable psychological treatments.

Thanks to Heather Gridley FAPS for arranging this interview.